Provider Demographics
NPI:1093828881
Name:THE CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC.-HOPE MEADOW PROGRAM
Entity Type:Organization
Organization Name:THE CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC.-HOPE MEADOW PROGRAM
Other - Org Name:FAMILY WELLNESS AND RECOVERY SERVICES OF NC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:SUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:919-933-0770
Mailing Address - Street 1:101 E WEAVER ST
Mailing Address - Street 2:STE. G-7
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-2370
Mailing Address - Country:US
Mailing Address - Phone:919-933-0770
Mailing Address - Fax:919-933-0767
Practice Address - Street 1:263 PENNY LN
Practice Address - Street 2:
Practice Address - City:PITTSBORO
Practice Address - State:NC
Practice Address - Zip Code:27312-4918
Practice Address - Country:US
Practice Address - Phone:919-968-8680
Practice Address - Fax:919-968-9970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CHRYSALIS FOUNDATION FOR MENTAL HEALTH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-019017324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110548Medicaid
NC8300816BMedicaid
NC8300816GMedicaid
NC8302193PMedicaid
NC8300816Medicaid
NC8300816PMedicaid
NC8302193GMedicaid
NC6005680Medicaid
NC6106030Medicaid
NC8302193Medicaid
NC6000789Medicaid
NC6103305Medicaid
NC8302193BMedicaid